Abstract No. 269 - Percutaneous trans-splenic embolization of roux limb varices in children with chronic portal vein occlusion (PVO) post orthotopic liver transplant (OLT)

Abstract

Purpose To report our technique of trans-splenic embolization for Roux limb variceal bleeding not amenable to endoscopic therapy in children. Materials and Methods Patient 1: 5 year old girl with chronic PVO post OLT for biliary atresia presented with chronic upper GI bleed and anemia requiring multiple transfusions despite adequate treatment of esophageal varices. MR and CT revealed heterotaxy, polysplenia with azygous vein connections and cavernous transformation of the portal vein. Enteroscopy could not detect these varices. Patient 2: 12 year girl with chronic PVO post OLT for biliary atresia presented with acute upper GI bleed. Upper GI endoscopy and enteroscopy were normal. CT abdomen showed varices within small bowel wall near the liver hilum. Technique: C-arm CT (syngo DynaCT ® , Siemens Medical Solutions USA Inc.) images were acquired using a 8-second DR body protocol with contrast injection into the superior mesenteric artery followed by delayed image acquisition during the venous phase to demonstrate the Roux limb varices with portoportal collaterals through the liver capsule into the intrahepatic portal branches. A 4F vascular sheath was placed within the splenic vein after accessing a peripheral splenic venous tributary using ultrasound. Superior mesenteric venography and selective venography of the Roux limb varices followed by embolization using microcoils, NBCA or Onyx was performed. Postembolization superior mesenteric venography and C-arm CT imaging in the venous phase were performed. Results Preembolization C-arm CT images were helpful in localization of the varices to the bowel wall and selection of varices for embolization. Patient 1 had successful initial resolution of GI bleed with recurrence at 4.5 months when further varices were embolized. At 14 month follow up since the second procedure there has been no further bleed. Patient 2 with acute GI bleed had cessation of bleeding and is stable at 1 month follow up. Conclusion A trans-splenic approach is a useful technique to embolize bleeding Roux limb varices which are beyond the reach of the endoscopist in the setting of portal vein occlusion in patents post OLT.